87-517 - Laserfiche WebLink

Home Browse Search

APPLICATION FOR PERMIT SAN JOAQUIN,LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 j PERMIT EXPIRES 1 YEAR FROM DATE ISSUED 1 (Complete in,Triplicate) Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein described.This application is made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District.'T f i Job Address l! / z "_ 2 Zr- -2c.c.tom✓ - �11 City Lot Size PM Owner's NamOL:' L / C t!/��.Q Address S3/Z / LC✓ ,6-c { Phone Contractor ! Address License No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP,dNSTALLATION ❑ SYSTEM REPAIR ❑ OTHER 13 DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications ❑ Public ❑ Other ❑ Delta Depth of,Grout Seal • Type of Grout ❑ Irrigation. �pprox.,bepth ._❑.Eastern .,,._..Surface Seal lnst811ed by --'-• - 3 z -- -__ Repair Work Done ❑ T r p Type of Pump H.P. State Work Done �- Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRU ION (No se tic system permitted if public sewer is - -avail le-within 200 feet.} Installation will serve: Residence Commercial— Other Number of living units: Nu4er of bedrooms Character of soil to a depth of 3 feet:♦ Water tabledepth SEPTIC TANK ElType/Mfg, Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal e Distance-to-nearest:— -Weil-------m--- Foundation a Property Lind t LEACHING LINE ❑ No. & Length of lines Total length/size e FILTER BED ❑ Distance to nearest: Well Foundation Property Line n- SEEPAGE PITS ❑ Depth + Size Number I SUMPS ❑ Distance to nearest: Well Foundation - Property Line DISPOSAL PONDS ❑ hereby certify that I have prepared this application and that the work will be done in accordance with San Joaqdin county ordinances, state laws, and rules and regulations of the San Joaquin.Local Health District. I Home owner or licensed agent's signature certifies the following: "I certify that in the performance of the work foriwhich this permit is issued, I shall not i employ any person in such manner as"to,become subject to workman's cQmpensation_iaws of_California.'Contractor"s.hiring_or-sub-contracting signature certifies the following:"I certify that in the performance of the work for which this permit is issued, I shall employ persons subject to workman's compensa- tion laws of California." _ � Thea applicant must call for all r I 1/ PP squired inspections. Complete drawing on reverse side. fined Tom_"� Title: # I Date:X 3 r FOR DEPARTMENT USE ONLY �7 Application Accepted by Date r r Area pe Y_ '�Final on by net, Pit or Grout Inspection b "`"'� p" " Additional Comments: Uh- CR ❑ Stk 466-6781 ❑ Lodi 369-3621 11 Manteca 823-7104 ❑ Tracy 835-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED C R RECEIVED BY DATE PERMIT'N0. I + EH 1a-241REV,tie5) �* �� B75ti EH 1428 — p